Dr RPH Peters, MD, PhD, DLSHTM

Clinical Programme Specialist

Janus – Roman God of transition

TB epidemic in South Africa (1)

WHO Global Tuberculosis Report 2013

TB epidemic in South Africa (2)

WHO Global Tuberculosis Report 2013

TB epidemic in South Africa (3)

WHO Global Tuberculosis Report 2013

What happened over time?

Churchyard GJ et al. S Afr Med J 2014

• Why talk about strengthening TB system?

• Who to target?

• What to do?

• How to achieve the objectives?

Tuberculosis and HSS

What is the goal of HSS?

Can elimination be achieved?

Dye C et al. Annu. Rev. Public Health 2013

TB-associated mortality in SA

Impact TB on daily life

• Patients and the community

• Healthcare workers

• Scientists

• Policy makers

• Biomedical Industry

• Pharmaceutical industry

• Advocacy groups

Who to target?

What to do?

Dye C et al. Annu. Rev. Public Health 2013

What to do?

• Patient education

• Impact of ART roll-out

• HIV/TB integration

• HCW skills development

• Early case detection of TB

• Xpert® MTB/RIF for diagnosis of TB

• Contact tracing

• Enhanced case management

• Other interventions & developments

Patients delays

Lusignani S et al. BMC Infect Dis 2013

People counselling required

Implement lessons learnt…

Is ART the answer?

Dodd PJ et al. PLoS One 2013

Is ART the answer?

Dye C et al. Annu. Rev. Public Health 2013

Is ART the answer?

Gupta A et al. PLoS One 2013

Let’s expand our focus from

‘integration’ to ‘intensified effort’

Kaplan R et al. PLoS One 2013

Healthcare workers knowledge

Engelbrecht M et al. S Afr J Epidemiol Infect Dis 2013

Facility

Engelbrecht M et al. S Afr J Epidemiol Infect Dis 2013

Early detection of TB (1)

• Symptom screening is implemented… but

do we really know what to look for?

Early detection of TB (2)

Claassens MM et al. Int J Tuberc Lung Dis 2013

• 443/665 (64%) symptomatic

Early detection of TB (3)

Do we really know what to look for?

• How about TB in children?

• Maternal and infant TB?

• How about extrapulmonary TB?

Xpert for diagnosis of TB (1)

Xpert for diagnosis of TB (2)

Theron G et al. Lancet 2013

Xpert for diagnosis of TB (3)

Hanrahan CF et al. PLoS One 2013

Xpert for diagnosis of TB (3)

Yoon CJ et al. PLoS One 2013

All TB patients Smear-negative TB

Xpert for diagnosis of TB (4)

Clinic-based

Xpert®

(n=264)

Laboratory-

based Xpert®

(n=154)

P-value

Median days to initiation of

TB treatment <1 (0-5) 7 (2-15) <0.001

TB case fatality rate at two

months 2/23 (8.7%) 1/16 (6.3%) 1.0

TB diagnosis at later stage

-Culture (MGIT)

-Chest X-ray

15 (5.7%)

8 (3.0%)

7 (2.7%)

5 (3.2%)

2 (1.3%)

3 (1.9%)

0.3

0.7

0.3

All cause mortality at two

months 6 (2.3%) 4 (2.6%) 1.0

Peters RP, In preparation

Contact tracing for early detection

Middelkoop K et al. S Afr Med J 2014

Creative ways of contact tracing

Mwansa J et al. PLoS One 2013

Enhanced case management..

Enhanced case management..

• Complicated cases?

• Adverse effects & drug interactions?

• Pharmacovigilance systems?

• Separate drugs vs. combination tablet?

• Drug levels (personalized medicine)?

Complexity of TB Disease

In summary (1)

• South Africa has one of the largest TB

epidemics in the world

• Progress made, but not on target

• Combined effort required:

– Patients and Healthcare workers

– Scientists

– Biomedical and pharmaceutical industry

– Advocacy groups and policy makers

In summary (2)

• Increase awareness, skills and diagnostics

and therapeutic resources

• Implement common knowledge and

lessons learnt

• Expand basic scientific knowledge of TB

• Development of new drugs and vaccine

• Role of funding and public health

commitment